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Peripheral Vascular Disease

GUNAWAN TOHIR FK UMP PALEMBANG 2012

Peripheral Vascular Disorders

Ischemia-lack of blood supply to meet the needs of the tissue. Causes of Ischemia

Atherosclerosis (fatty deposits) Thrombosis/blood clot/embolism

vasoconstriction occlusion of lumen of the artery due to:

s/s = coldness, pallor, or rubor (redness), cyanosis (blueness) pain, changes in skin or nails

PRIMARY SITES OF INVOLVEMENT


Femoral & Popliteal arteries: 80-90% Tibial & Peroneal arteries: 40-50%

Aorta & Iliac arteries: 30%


Harrisons Principles of Int Med

PVD

DOPPLER

Peripheral Arterial Occlusive Disease (830)

Pathophysiology: Narrowing and sclerosis of large arteries (femoral, iliac, popliteal) especially at bifurcations due to plaque formation Risk factors: smoking, obesity, sedentary lifestyle, HTN, DM, hyperlipidemia, Fa hx S/S: see previous slide. May also have bruit over femoral or popliteal : doppler area Dx Tests: US, exercise testing (822), pulse volumes, angiography (823), Trendelenberg test (see Assessment text)

Peripheral Vascular Diseases

Arterial Manifestations:

Venous Manifestations:

Diminished or absent pulses Smooth, shiny, dry skin, no hair No edema Round, regularly shaped painful ulcers on distal foot, toes or webs of toes Dependent rubor Pallor and pain when legs elevated Intermittent claudication Brittle, thick nails

Normal pulses Brown patches of discoloration on lower legs Dependent edema Irregularly shaped, usually painless ulcers on lower legs and ankles Dependent cyanosis and pain Pain relief when legs elevated No intermittent claudication Normal nails

Physical Assessment of PVD

Arterial disease:

acute pain,intermittent claudication (pain increases with exercise, relieved with rest), hair loss distant with occulusion, thick brittle nails

Parasthesia, pallor when limb elevated, rubor when limb dependent(down), skin temp cold, dimished/weak/or absent pulses, no edema, but ulcers in distal areas, foot, toes, ankles, calves

Physical Assessment of PVD

Venous disease

little or no pain, some tenderness along inflamed vein, no hair loss, skin color brawny(reddishbrown),cyanotic if dependent position

Veins may be visible, warm skin temperature, edema typically present, pulses normal and present/palpable, no changes in hair or nails, little skin breakdown (ulcers)

Risk Factors-PVD

Being a man over age 50 yr. of age cigarette smoking hypertension, high cholesterol heart disease and diabetes inability of the kidneys to filter out waste products

And maintain fluid balance no/little exercise obesity wearing tight obstructive garments/girdles, elastic top socks/garters

HOW DOES AN INTERMITTENT CLAUDICATION PATIENT PRESENT CLINICALLY?

Leg pain caused and reproduced by a certain degree of exertion Relieved by rest Not affected by body position Atherosclerotic lesions usually found in arterial segment one level above affected muscle group Calf claudication more commonly due to disease in femoral arteries and less commonly due to disease in popliteal or proximal tibial or peroneal arteries; Hip/Thigh/Buttock claudication due to aortoiliac disease

Am J Cardiol 2001; 87 (suppl): 3D-13D

DIFFERENTIAL DIAGNOSIS CALF HIP/THIGH/BUTTOCK


Venous

occlusion Tight bursting pain / dull ache that worsens on standing and resolves with leg elevation Positional pain relief Chronic compartment syndrome Tight bursting pain Positional pain relief Nerve root compression Positional pain relief

Arthritis Persistent pain, brought on by variable amounts of exercise Associated symptoms in other joints Spinal cord compression History of back pain Symptoms while standing Positional pain relief FOOT Arthritis Buerger disease (thromboangitis obliterans)
Am J Cardiol 2001; 87 (suppl): 3D-13D

DIAGNOSIS

History taking Careful examination of leg Pulse evaluation Ankle-brachial index (ABI): SBP in ankle (dorsalis pedis and posterior tibial arteries) ___________________________________ SBP in upper arm (brachial artery)

Am J Cardiol 2001; 87 (suppl): 3D-13D NEJM 2001; 344: 1608-1621

Ankle-Brachial Index Values and Clinical Classification


Clinical Presentation
Normal

Ankle-Brachial Index
> 0.90

Claudication
Rest pain

0.50-0.90
0.21-0.49

Tissue loss

< 0.20
Am J Cardiol 2001; 87 (suppl): 3D-13D NEJM 2001; 344: 1608-1621

Values >1.25 falsely elevated; commonly seen in diabetics

The history and physical examination (pulse evaluation and careful examination of the leg) are usually sufficient to establish the diagnosis

Poin positif

Diagnostik Buerger nilai positif


Kriteria Usia onset Klaudikasio intermiten kaki Ekstremitas atas Tromboflebitis superficial migrans +1 30-40 tahun Ada riwayat asimptomatik Ada riwayat +2 <> Ada saat pemeriksaan Simptomatik Ada saat pemeriksaan

Fenomena Raynaud Angiografi, biopsi

Ada riwayat Khas untuk salah satu

Ada saat pemeriksaan Khas untuk keduanya

Nilai negatif
Kriteria Usia onset Jenis kelamin, kebiasaan merokok -1 45-50 tahun wanita -2 >50 tahun Tidak merokok

lokasi

1 ekstremitas

Tidak ada ekstremitas yang terlibat

Hilangnya pulsasi Artiosklerosis, hiperlipidemi DM,

brakial hipertensi, Terdiagnosis dalam 5-10 tahun kemudian

Femoral Terdiagnosis dalam 2-5 tahun kemudian

Interpretasi

Interpretasi dari total poin-poin tersebut antara lain 0-1 diagnosis Buergers disease tersingkirkan 2-3 tersangka, probabilitas rendah 4-5 probabilitas sedang 6 probabilitas tinggi, diagnosis dapat dipastikan

Raynauds & Buergers DZ

Raynauds-periodic constriction of arteries that supply extremities, mostly hands and feet arteriospastic (pulses never absent) spaz-out! Freq. Young women s/s usually precipitated by

Exposure to cold, emotional upset, tobacco usage. 3-color changes, vasoconstrictive pallorcyanosis-rubor or hyperemia cold, numbness, pain,tingling,swelling lasts minutes-hrs.

Continued: Raynauds disease

Pallor-cyanosis (especially fingers)painful-aching painclient learns warmth relieves pain-go inside warm, or placed in warm water-which relieves vasopsasmsblood rushes to the extremity

Ulcers/gangrene & pain may appear at fingertips with chronicity TX-prevent chilling, avoid risk factors, no ETOH,tobacco, wear gloves, heat, vasodilators, avoid stress

Buergers dz (arterial/venous) thromboangitis obliterans

Inflamm. Of bld vessels (arteries/veins) and formations of clots (thrombus) usually lower extremities association: tobacco usage,men 25-40yrs

S/S- my foot fell asleep,foot always cold, cyanosis,redness/ mottled-purplish-red of the foot/leg, pain, phlebitis may occur, ulcers,gangrene, changes skin/nails if circl. is impaired

Acute Arterial Occlusive Disease (arterial embolism-840)

Pathophysiology: blood clots from arteries, left ventricle, or trauma suddenly break loose and become free flowing, lodge in bifurcations, causing obstruction distally with acute and sudden symptoms Assessment: +6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia), ABI<1, +US, MRI, or angiography

Management of Arterial Embolism

Medical:

Anticoagulants-heparin bolus then 1000U/hr Thrombolytics

Surgical (depends on occlusion time):

Embolectomy (840) Bypass Angioplasty with stent placement


Administer and monitor anticoag or thrombolytic tx If surgery, then monitor for postop angioplasty and stent placement, bypass, or embolectomy (similar to bypass except no ICU and hospital time is less).

Nursing:

Buergers Disease (thromboangiitis obliterans-834)

Pathophysiology: obstructive and inflammatory disease of small and medium sized arteries and veins. Believed to be autoimmune. Has exacerbations and remissions. Smoking is very high risk factor. Assessment: pain and instep claudication, intense rubor, absence of distal pulses (pedal, radial, ulnar), paresthesias; segmental limb blood pressures, US, angiography

Management of Buergers Disease

Medical/Surgical:

Pain meds Stop smoking Treatment of infection and gangrene Sympathectomy (removal of sympathetic ganglia or branches-causes permanent vasodilation Amputation Support stopping smoking Administer pain meds Education regarding protection extremities from cold and trauma.

Nursing:

Raynauds Disease (841)

Pathophysiology: arterial spasms of small cutaneous vessels of fingers and toes. May have too many alpha 2 receptors leading to vasoconstriction and not enough beta receptors. Aggravated by cold and stress. Assessment: classic tri-color symptomspallor, cyanosis, rubor, pain, and paresthesia. Bilateral and symmetric.

Management of Raynauds Disease

Medical/Surgical:

Avoiding cold, stress, nicotine Ca++ channel blockers (particularly nifedipine) especially for acute vasospasm sympathectomy Avoid stress, take stress mgmt classes Avoid cold and trauma Teach about nifedipine (can cause orthostatic hypotension)

Nursing:

Hypertension (855)

Definitions and Etiology:


SBP > 140 and DBP > 90 at least 3 times. Affects 20-25% of population. 90-95% have primary or essential HTN (unknown etiology). Other 5-10% have secondary, meaning there is a disease process causing it (i.e., thyrotoxicosis, renal artery stenosis, pheochromocytoma). Hypertensive crisis-DBP > 120. Malignant HTN-rises rapidly. White coat HTNincreased BP when patient goes to MD. Risk factors are similar to CAD Classifications p. 855, Table 32-1

Assessment of HTN

S/S:

Dx Tests:

Usually absent unless severe or advanced If symptoms they include HA, blurred vision, dizziness, nosebleeds BP > 140/90 S4 gallop rhythm

BP readings CBC, UA, lytes, lipids, glucose, renal and liver functions ECG CXR Echo

TX-management of Buergers Disease

No tobacco , avoid factors cause vasoconstriction Avoid becoming chilled, wear warm socks, boots, gloves, warm water baths Avoid prolonged standing- job changes? Nursing?

Avoid injury/infection exercising to stimulate circulation, however, as long as it doesnt cause pain Buerger-Allen exercisesDo not keep legs elevated-ischemia vasodilators/anticoagulants may help

Buerger-Allen exercises

Elevate feet/legs till feet blanch(whitish), then lowering them till turn red, then resting legs/feet in a horizontal position. Client performs exercises lying in bed or on sofa. Dr. tells client how often to perform them

The client is instructed to watch the changes in color blanching indicates inadequate blood. Supply-maintaining this position could harm tissues (death) May instead walk, foot exercises help too

Varicose Veins-dilated tortuous veins, with incompetent valves

Competent Valves allow bld. To return to the heart and prevent back-flow Risk factors: obesity, standing in 1 place too long, pregnancy constriction and or pressure on the legs

Generally, bld collects Saphenous Vein, Superficial Veins dilated and distended, dark blue purplish swellings c/o legs tired/heavy feeling, cramping pain

TX & Management of Varicosities

TX: ligation/strippingmay use surgical or more likely lasar tx. Zap- them DX- Doppler studies Injection sclerotherapy- old tx Prevention-Best Tx

Avoid sitting/standing for long periods of time maintain ideal body weight avoid injury to legs no crossing legs no constrictive clothing/hosiery

Continued Tx: Varicosities

Elastic stockings long(TED) hose- removed once q 8hr. X 30min. Check skin Promote circulation Taught to apply hose while lying in bed w/ legs elevated Change position frequently

Keep legs elevated at rest, to promote venous return back to the heart Avoid infections, wear comfortable but supportive shoes Maintain weight

Disorders of veins-most common is thrombophlebitisformation of a thrombus (clot)in association with inflammation of vein Etiology- 3 things

Classified as either superficial or deep 65% IV therapysuperficial; 5% of surgical patients-deep, especially bedrest, long abdominal surgery, hip, anything causes venous stasis Worry clot-travels or emboli to lung, heart, brain

In 1846, Virchows Triad: formation of clot 1.venous stasis/pooling 2.damage of endothelium or inner lining of vein 3. hypercoagulabilty of bloodare your clients high risk to any of these? Prolonged bedrest, obesity,varicose veins, hip/knee replacements, Oral contraceptives.

Thrombophlebitis- superficial or deep (DVT)?


Superficial palpable, firm, cordlike vein, surrounding vein, warm, reddened, tender, edema maybe IV therapy-arms varicose veins-legs

Deep- DVT no s/s in 50% of cases or unilateral leg edema/swelling, pain, warm skin, mild temp, cyanosis possibly, Positive Homans sign: pain upon dorsiflexion of foot - but not always present in all cases

Dx- thrombophlebitis-Various ( venogram, non-invasive doppler studies, coagulation studies PT,PTT,platelet ct., bleeding time, INR, arteriogram, Lung scan if emboli?

Conservative tx: bedrest with leg elevated until tenderness is reduced about 5-7 days. Warm moist heat (K-pad) may be used to relieve pain and inflammation Dont massage legs

Pain control/antiinflammatory drugs If edema- TED hose or ace (elastic) wraps Anti-coagulants like Heparin Drip- IV(DVTs only) bleeding and safety precautions

Cont. TX/Management thrombophlebitis

Pharmacological Txaimed to prevent clots, dont dissolve them (Heparin/Lovenox-SQ/ Coumadin-po.) Heparin/Lovenox-SQlw. Abdomen 2 inches away umbilicus

Dont rub with alcohol pad after shot, use 5/8 inch needle SQ- no more than 1cc ever injected into tissue or one site, if more needed use divided doses.

Cont. general guidelines thrombophlebitis/DVTs


Measurement- of both legs/calves Heparin/Coumadin Coumadin is started while on Heparin-IV; Monitor PT, (A)PTT, INRantidote coumadin is Vit.K Heparin-Protamine sulfate antidote

Avoid aspirin while on anti-coagulants like Heparin/Coumadin Nurse recognize high risk patients for thrombophlebitis, bedrest, age, dehydration, oral contraceptives, steroids, IV drug use

Continued: thrombophlebitis/DVTs

If on Heparin/Coumadin- s/s bleeding gums, urine, stool, any orifice, bruising, epistaxsis, petehiae, no foley, no rectal temp, no IM injections

Always check lab values PT- & INR for Coumadin (A)PTT & INRHeparin (IV) 5000 u Heparin SQ considered low dose prophylaxsis/mainten ance dosage

Cont. DVT-thrombophlebitis

Elastic stocking (TED) hose-properly measured, fitted, and evenly applied stockings compress superficial veins & prevent venous stasisor pnuematic alternating compression boots

Prevent pressure under the knee avoid pillows/knee gatches on bed) No pressure on popliteal space Avoid OC with recurrent thrombophlebitis rest/exercise/fluids

More general guidelines

Avoid prolong sitting-pressure under knee Elderly, heart dz, infection, dehydration most proned to thrombophlebitis Avoid prolong sitting car/airplane/bus ride

Or sitting in front of TV long period of time (Sedentary lifestyle) Change positions frequently and exercise legs at intervals is necessary Avoid standing long period of time too!

Lab values for Coumadin/Heparin


Coumadin/warfarin : Check the PT (prothrombin time) Want the PT about 1.52.0 times control value (normal for adults=10-13 sec) INR you want a target level for coumadin or warfarin therapy between (2.0-3.0) for most conditions like DVT, hip surgery etc. INR is more reliable test than PT/PTT

PTT or APTT (partial thromboplastin time or activated partial thromboplastin time) Used in Heparin therapy & also INR too! PTT control=60-70 sec; and APTT=20-35 sec. Want 1.5-2.5 times control value in seconds for optimal anticoagulant therapy Most cases: INR level to be within (2-3)